Root-Cause-Analysis. Effectively Responding to Accidents and Incidents. The Mind-set of a CSI 4/17/2017

Transcription

1 Root-Cause-Analysis Effectively Responding to Accidents and Incidents Chuck Bosen, RN Director of Clinical Services - Western Division Idaho Health Care Association Work Shop April 26 th, 2017 The Mind-set of a CSI 1

2 Why Root Cause Analysis? Root cause analysis transforms an old culture that reacts to problems, into a new culture that solves problems before they escalate. Aiming performance improvement operations at root causes is more effective than merely treating the symptoms of problems. Problems are best solved by eliminating and correcting the root causes, as opposed to merely addressing the obvious symptoms with scatter-gun approaches to solutions. What Will We Discover? Problems are frequently the fault of a system, not an individual. (Hoyer) Change the people without changing the system, the problems will still continue. Root cause analysis will shed light on appropriate interventions to minimize or eliminate risk to the resident which closes the door on risk to your company/organization! 2

3 Focus on Nursing Strategies Utilize our skill in symptomatology and our knowledge of pathological evidence to determine a root cause. Look Right Feel Right Smell Right issues will be addressed with recommendations that focus on the fundamentals. The goal of our recommendations is to modify an operational system to enhance process improvement. Set our staff up for success! Resident outcome data will be our measure of improvement or need for further support. We want sharper criticalthinking skills on display. Cultural Goal for Assisted Living Adopt the process of root cause analysis. Identify better INTERVENTIONS. Reduce the impact and frequency of risky resident events. Set a pattern that sets the staff up for success. 3

4 The Number One Indicator What single indicator should be on the forefront of the clinician when evaluating a residents pre-disposition to falling? Anti Depressants Who is at RISK for FALLS???? 4

5 Who is at Risk for Falling? High Risk Criteria Adults 45 and older Sedentary Multiple Co-Morbidities (Diabetes, HTN, GERD, Obesity) Compounded by Cognitive Issues Factors Contributing to Falls Vasovagal Response.. Makes up 6% of hospital admissions Impacts 23% of institutionalized geriatric residents Root Cause Analysis PRUNES! The Four P s of Falls.. Potty Pain Positioning Personal Items 5

6 Internal Evidence and Clues: o What was the resident doing or trying to do just before they fell? Ask them. All Residents.All the TIME! o Place of falls At the bedside.orthostatic 5 feet away Balance/Gait 15 feet away Strength/Endurance 10 QUESTIONS TO ASK WHEN A RESIDENT FALLS CL INICAL SERVICES Clinical Services 10 Questions to Ask When a Resident Falls Page 1 of 1 EMG QA / Approved Forms / Falls/Fall Reduction Forms Revised 6/ What were you doing just before the fall? 2. What were you trying to do? 3. What was different this time? 4. What is/was the position of the resident? (Was fall near bed, toilet, chair, etc.? If so, how far away?; Was resident on their back, front, L or R side?; What was the position of the arms and legs?) 5. What is/was the surrounding area like? (Was it noisy, busy, cluttered, etc.?; If fall was in the bathroom, what were the contents of the toilet?; Was there poor lighting?; What was the position of furniture and equipment? Was the bed the correct height?) 6. What is/was the floor like? (Was the floor wet?; Was there urine on the floor?; Was the floor uneven?; Was the floor shiny?; Did the fall occur on carpet or tile floor?) 7. What is/was the resident s apparel? (Was the resident wearing shoes, socks (nonskid), slippers, bare feet, etc.) 8. Was the resident using any assistive devices? (Walker, cane, wheelchair, merry walker, etc.) 9. Did the resident have glasses and/or hearing aids on? 10. Who was in the area when the resident fell? 6

7 Together Everyone Achieves More Case Study Susy Fell; 78 y/o female; lives in MC unit; Dx of HTN, DM, Dementia, constipation, etc. lives in rm. 11. Observed lying on BR floor at 10:15 PM on 11/14/13. redness to knees bilat; no sx of hitting head; denies pain, urine and small stool in toilet; toileted at 8:15 PM before bed; bedding on the floor; last BM recorded on 11/12/13; VS: 98/54, 18, 58, She says that she was trying to be a good girl Last checked at 9:45 PM and was sleeping in bed. 7

8 Moving Forward I did then what I knew then. When I knew better I did better. Maya Angelou 8